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Project HIE STANDARD
Medical underwriting is an insurance term referring to the use of medical or health status information in the evaluation of an applicant for coverage (typically for life or health insurance). As part of the underwriting process, health information may be used in making two related decisions: whether to offer or deny coverage; and what premium rate to set for the policy. The use of medical underwriting may be restricted by law in certain insurance markets. Where allowed, the criteria used should be objective, clearly related to the likely cost of providing coverage, practical to administer, consistent with applicable law, and designed to protect the long-term viability of the insurance system.
The use of medical underwriting in the individual health insurance market has met with some controversy. While medical underwriting is designed to keep premiums as low as possible, critics say that the practice prevents some people with relatively minor and treatable pre-existing conditions from obtaining health insurance. Some states have outlawed medical underwriting as a condition for obtaining insurance; these states generally have the highest average premiums for individual insurance. Insurance providers will often carefully analyze possible client health information. Factors such as probability, thinking short term, and studying medical history and genetic susceptibility are all practices insurance providers use.
From the insurers' point of view, medical underwriting is necessary to prevent people from purchasing health insurance coverage only when they are sick, pregnant or need medical care. This tendency is called "adverse selection," i.e, a system which attracts high utilization users while discouraging low utilizers from participating. Proponents of underwriting believe that, if given the ability to purchase coverage without regard for pre-existing medical conditions (i.e., no underwriting), people would wait to purchase health insurance until they got sick or needed medical care. Waiting to obtain health insurance coverage until one needs coverage then creates a pool of insureds with "high utilization," which then increases the premiums that insurance companies must charge in order to pay for the claims incurred. In turn, high premiums further discourage healthy people from obtaining coverage — particularly when they realize that they will be able obtain coverage when they need medical care. It is estimated that nearly 1.6 million Americans experience medical underwriting every year.
Proponents of medical underwriting thus argue that it ensures that individual health insurance premiums are kept as low as possible. Critics of medical underwriting believe that it unfairly prevents people with relatively minor and treatable pre-existing conditions from obtaining health insurance. Diseases that can make an individual uninsurable include serious conditions, such as arthritis , cancer, and heart disease, but also such common ailments as acne, being 20 pounds over or under weight, and old sports injuries. An estimated 5 million of those without health insurance are considered "uninsurable" because of pre-existing conditions.
One large industry survey from 2004 found that roughly 13% of those who applied for individual health insurance were denied coverage after undergoing medical underwriting. Declination rates increased significantly with age, rising from 5% for individuals 18 and under to just under a third for individuals aged 60 to 64. The same study found that, among those who received offers for coverage, 76% received offers at standard rates; 22% were quoted higher rates. The frequency of increased premiums also increased with age, so for applicants over 40, roughly half were affected by medical underwriting, either in the form of denial or increased premiums. The study did not address how many applicants offered coverage at higher premiums decided to decline the policy. A study conducted by the Commonwealth Fund in 2001 found that, among those aged 19 to 64 who sought individual health insurance during the previous three years, the majority found it unaffordable, and less than a third ended up purchasing insurance. However, this study did not distinguish between consumers who were quoted increased rates due to medical underwriting and those who qualified for standard or preferred premiums.
Measuring the percentage of applicants who were denied coverage does not capture any effect that occurs before an application is submitted. If individuals with serious health conditions never apply because they expect that they will be denied coverage, they will not show up in the declination rate. Conversely, if they apply with multiple insurers in hopes of finding one that will issue them a policy, they will be over-represented in the declination rate. The 2001 Commonwealth Fund study found that a majority of adults reported that it was at least somewhat difficult to find an affordable health insurance policy. Among adults over 30, the percentage reporting difficulty did not vary significantly by age. Those with health problems were somewhat more likely to report having difficulty obtaining affordable health insurance (77% versus 64% of those in good health).
Some American states have made medical underwriting illegal as a prerequisite for health coverage, which means if you ask for health insurance and pay for it, you get it. These states also have the highest premiums for individual health insurance.
In most states, individual health insurance policies are "guaranteed renewable," meaning that once a policy has been issued, the policyholder can keep it forever — regardless of medical conditions — as long as the required premiums are paid. There have been instances where insurers have increased premiums at annual renewals based on an individual's claim history or changes in their health status. This was possible when coverage was marketed to individuals through discretionary group trusts, escaping some states' rules governing the individual health insurance market. The insurer that was first identified by
The Wall Street Journal
as reunderwriting policyholders has since publicly stated it will discontinue the practice.
However, in most cases an insurer's ability to "re-underwrite" an existing guaranteed renewable policy is limited by contract provisions and state law. Even so, premiums can rise significantly for existing policies if the average health of the policyholders with a particular product deteriorates. This often happens when rising premiums drive healthier individuals (who can buy another policy on favorable terms) out of the product, leaving only those who are relatively less healthy. One factor driving this is the increase in costs as individuals who initially pass underwriting develop health problems. In general, claim costs rise significantly over the first five years that an individual health insurance policy is in force.
Several solutions have been proposed for this "closed block" problem, including requiring insurers to "pre-fund" for cost increases over the lifetime of a product, provide cross-subsidies between blocks of products by pooling products across durations, provide cross-subsidies by placing limits on the allowed variation in premiums between products, or create state-sponsored risk pools for individuals trapped in a closed block. The American Academy of Actuaries performed a study of these proposed solutions for the National Association of Insurance Commissioners and modeled the likely impact of each. All of these solutions would increase the initial cost of a new policy and reduce cost increases over time.
Medical Underwriting Guidelines:
Milliman's Small Group Medical Underwriting Guidelines (SGMUGs) and Individual Medical Underwriting Guidelines (IMUGs) are
evidence-based medical underwriting tools that use a debit-point system to enable underwriters to more objectively underwrite initial
applications for individual and group coverage.
Real-world medical expenses for evidence-based decision making
These Guidelines include an index of approximately 1,500 medical conditions and 2,000 prescribed drugs that permit insurers to easily
estimate the costs of treating the conditions and conditions associated with prescribed medications. The Guidelines are based on data
gathered from real claims of 15 million members and 10 years of longitudinal research.
By making the evidence-based medical research instantly available to underwriters in easily accessible formats, Medical Underwriting
Guidelines can improve the accuracy and sophistication of underwriting. Underwriting staff can save time looking for information and
maintaining files, which means they can decrease quote turnaround time and focus on their expertise.
Convenient formats, automated reporting and record keeping
SGMUGs and IMUGs, which are leased on an annual basis, are published in traditional binder format and are also available in our
Internet-based software application, WebMUGS™. The electronic format combines the Guidelines research with automated reporting and
record-keeping functions. Reports on most frequent conditions, average group debit points, and individual rating factors can
be automatically generated, allowing greater transparency and more objective decision making. Electronic formats also track
underwriting decisions to enable quick and simple compliance with documentation requirements.
Real-Time Medical Underwriting:
Real-time Medical Underwriting is a true turnkey solution that allows you to generate quotes faster and with statistically greater accuracy than ever before, so you can act more quickly and strategically on market opportunities.
Real-time Medical Underwriting allows you to…
• Increase accuracy
• Accelerate speed to quote
• Expand sales opportunities
Tips for Medical Underwriting (From the providers point of view)
How much underwriting occurs?
Health Insurance - Insurance against the risk of incurring medical expenses among individuals
Medicare - Social Insurance program administered by the US government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other special criteria
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